FROM : dPdiatrics Associates of_Hmstd FAX NO. : Feb. 12 2802 12:33PM Pl STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION , afc APTMENT CLERK @ STATE OF FLORIDA, AGENCY FOR HEALTH CARE V5 Me ADMINISTRATION, Boy xP oo » Petitioner, 2 rae) py vs. ; Audit No. CI 94-1086-000%), a Provider No. 0682519-00 2 DORSEY L. GOOSBY, M.D., 0 [664 FF Respondent. / FINAL ORDER THIS CAUSE is before me for issuance of a Final Order. Ina letter dated March 7, 2001, Respondent was informed the agency was seeking to recoup Medicaid overpayments of $426, 030. 23. “the letter was sent. Certified Mail, return receipt requested, , to Respondent, who signed for it on March 9, 2001. The letter contained full disclosure and notice regarding Respondent's administrative hearing and due process rights. To date, Respondent has not requested a hearing to dispute the facts contained in the letter. FINDINGS OF FACT The Respondent received the letter and that the letter disclosed the Respondent's administrative and due process rights. The Respondent has chosen not to dispute the facts set forth in the letter. Therefore, those facts, each and every one, are EXHIBIT ~ > ta | FROM : dPdiatrics Associates of _Hmstd FAK NO. : Feb. 12 2082 12:34PM P2 hereby deemed admitted, and form the factual basis for the existence of an overpayment owed by Respondent, in the amount of $426,030.23. That amount is now due and owing, with interest, since_the date of assessment, as more fully set forth below. CONCLUSIONS OF LAW The Agency incorporates and adopts the statements and conclusions of law as set’ forth in the letter dated March 7, 2001. The admitted facts support the conclusion that the amount of the stated overpayment is due and owing, under the law generally set forth in the final audit letter. BASED on the forgoing, it is ORDERED and ADJUDGED that Respondent refund, forthwith, the sum of $426,030.23, together with statutory interest as set forth in §409.913(24) (b), Florida Statutes, from the date of assessment. DONE and ORDERED this Ae ca of Tishary 2002, in Tallahassee, Florida. fr saescy e Medows, MD, FAAFP, Secretary Agency for Health Care Administration FROM : dPdiatrics Associates af_Hmstd FAX NO. : Feb. 12 2802 12:34PM PS A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENC¥Y MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: L. William Porter II Assistant General Counsel Agency for Health Care Administration (interoffice mail) Dorsey Goosby, M.D. 151 Northwest 11™ Street, Suite E202 Homestead, Florida 33030 (U.S. mail) Charles G. Ginn, Chief, Medicaid Program Integrity (interoffice mail). Willie Bivens, Finance & Accounting (interoffice mail) . Vicki Stiles, Medicaid Program Integrity FROM : dPdiatrics Associates of _Hmstd FAX NO. : Feb, 12 2022 12:34PM P4 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served on the above-named persons ( U.S. Mail interoffice mail as indicated on this the day of (eye. , 2002, Agency Clerk State of Florida Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5865 JUN = | 200! STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION DORSEY L. GOOSBY, M.D. AHCA Case No.: C.I. 94-1086-000/WG2/VAS. Petitioner, i Vs. AGENCY FOR HEALTH CARE ADMINISTRATION Respondent. PETITION FOR FORMAL ADMINISTRATIVE HEARING Petitioner, Dorsey L. Goosby, M.D., by his undersigned attorneys, petitions for a formal administrative hearing pursuant to Section 120.57(1), Florida Statutes, stating: 1. Petitioner is Dorsey L. Goosby, M.D., 151 Northwest lith Street, Suite E 202, Homestead, Florida 33030. Petitioner’s telephone number is 305-245-3220. For the purpose of this proceeding, however, Petitioner’s address and telephone number is that of the undersigned attomeys. 2. The agency affected by the Petition is the Agency for Health Care Administration (“AHCA”), 2727 Mahan Drive, Tallahassee, Florida 32308. 3. Petitioner’s substantial interests are affected by this proceeding in that AHCA reviewed Petitioner’s Medicaid claims for the period January 1, 1995 through December 31, 1997 and is seeking a recoupment of payment made in the amount of $426,030.23. 4. Petitioner initially received notice of this proposed administrative action through a Preliminary Agency Audit Report dated September 14, 2000. The Final Agency Audit Report was dated March 7, 2001, and was received by Petitioner some time around March 12, 2001. Petitioner EXHIBIT i 6 provided the Final Agency Audit Report to his insurance company on or about March 19, 2001 with the expectation that the insurance company would handle the matter as is provided in the insurance policy. 5. Petitioner’s counsel did not receive the Final Agency Audit Report from the insurance company until May 23, 2001. Due to excusable neglect, this Petition for Formal Administrative Hearing was not filed within the the 21 days allowed to request a formal hearing. However, Florida ~ courts have held that a request for an administrative hearing is not a jurisdictional defect and is subject to equitable considerations. See Unimed Laboratories, Inc. v. Agency for Health Care Administration, 715 So.2d 1036, 1037 (3d DCA 1998). This Petition for Formal Administrative Hearing is timely filed given the above described excusable neglect. 6. The basis of the determination of overpayment of Medicaid claims to the Petitioner is apparently based on the fact that Medicaid will not pay for claims when the participating provider has not followed the guidelines set forth in the applicable rules and Medicaid fee schedules. Petitioner contends that he has substantially complied with the Medicaid guidelines and disputes the allegations contained in the Final Agency Audit Report. The statistical methodology used by AHCA to produce the overpayment amount is flawed and overstates the amount of the overpayment. For example, one physician was employed in Petitioner’s group for only four months of the audit period, while the methodology to determine overpayment considered the physician employed for the full three year audit period. The allegations regarding improper coding are exaggerated and the assertion that Petitioner was overpaid by Medicaid is overstated. The office records and hospital records indicate that Petitioner properly documented services to Medicaid patients and validated with signature said records in compliance with Medicaid guidelines. 7. Petitioner did not violate Medicaid guidelines applicable to group member numbers. Certain physicians were not part of Petitioner’s group, but simply shared on-call coverage with Petitioner on an informal basis. Petitioner’s care of anew bom infant is appropriately covered under the mother’s Medicaid number, and the audit failed to consider this situation. 8. Following the issuance of AHCA’s Preliminary Agency Audit Report on September 14, 2000, Petitioner provided additional documentation to AHCA demonstrating that the amount of ‘the overpayment was overstated. Petitioner is prepared to present additional information and medical records (both office records and hospital records), and is prepared to demonstrated that the amount of the alleged overpayment is overstated. 9. A. The disputed issues of material fact include, but are not limited to, the following: Whether the level of service coded was, in fact, incorrect resulting in overpayments to Petitioner; Whether Petitioner inappropriately billed and was paid for consultation services and office visits, and whether Petitioner improperly documented and failed to preformed the prerequisites required to bill Medicaid for consultations; Whether additional hospital records are, in fact, available and should be reviewed; Whether additional office records are, in fact, available and should be reviewed; Whether physicians who merely provided on-call coverage for Petitioner should have been considered as “physician group providers”; Whether, when an infant is covered under the mother’s Medicaid number, the claim was appropriately reviewed; Whether the statistical methodology addresses the fact that one of the physicians noted as a non “physician group provider” was only employed four months of the audit period, but the experience is computed over the entire period; H. Whether the medical records were properly attested to and validated by Petitioner’s signature; and L Whether the statistical methodology used by AHCA accurately estimates the alleged overpayments to Petitioner. 10. The ultimate facts alleged by the Petitioner include, but are not limited to, the following: “A. " ” Petitioner properly coded for the services rendered to Medicaid patients and properly billed and received payment from Medicaid for said services; B. Petitioner properly documented medical records and attested to services provided to Medicaid patients; Cz Medicaid provider numbers used to bill Medicaid for services were appropriate; D, The statistical methodology used by AHCA to determine overpayment is flawed and overstated the amount of the overpayment. WHEREFORE, Petitioner requests that the Petition be transferred to the Division of Administrative Hearings for the appointment of an Administrative Law Judge, who will conduct a hearing in accordance with Section 120.57, Florida Statutes, after which a recommended and final order be entered denying in whole or in part recoupment of payments in the amount of $426,030.23. Florida Bar No. 989924 JAN J. GORRIE Florida Bar No.110906 PENNINGTON, MOORE, WILKINSON, BELL& DUNBAR, P.A. 215 South Monroe Street Second Floor (32301) Post Office Box 10095 Tallahassee, Florida 32302-2095 Telephone: 850-222-3533 Facsimile: 850-222-2126 PENNINGTON, Moore, WILKINSON, BELL & DunBaR, P.A. Attorneys At Law JOAN H, ANDERSON WILLIAM H. HUGHES, Ili CYNTHIA S. TUNNICLIFF TALLAHASSEE OFFICE: DOUGLAS S. BELL KORY J. ICKLER WALCIAM 5 NEUTNEY 215 SOUTH MONROE S$ SAMUEL P. BELL, Il KIMBERLY L. KING Ree MERION 2ND FLOOR FREDERICK L. BUSACK STEVEN M, MALONO TALLAHASSEE, FLORIDA 32301 KAREN M, CAMECHIS. EDGAR M, MOORE QF COUNSEL (850) 222-3833 KEVIN X. CROWLEY E. MURRAY MOORE, JR. ROBERT CINTRON, JR. R. STUART HUFF, P.A. MARK K. DELEGAL BRIAN A. NEWMAN Con eaniee hee . TAMPA OFFICE: MARC W. DUNBAR JULIUS F. PARKER, Ill CHRISTOPHER W. KANAGA* PETER M. DUNBAR JOHN C. PELHAM tAdmitied in Massachusetts & Coiorade Only) 7650 COURTNEY CAMPBELL MARTHA J, EDENFIELD CARL A, PENNINGTON, JR., P.A, CAUSEWAY. SUITE 220 CYNTHIA SIMMONS FLETCHER C. EOWIN AUDE, JR. SPECIAL CONSULTANTS (813)639-9599 ROGELIO J. FONTELA GARY A. SHIPMAN FETE MITCHELL® JAN J, GORRIE STEPHEN L. SPECTOR R.Z, SAFLEY* MARK T, HANEY FAX (813) 639-1488 WILEY HORTON “not 2 member of the Florida Bar EMAIL: emsil@penningtonlawfirm.com REPLY TO: P.O. BOX 10095 June 1, 2001 TALLAHASSEE, FL 32302-2095 Mr. Rufus Noble, Inspector General Medicaid Program Integrity Office of the Inspector General bac] 2727 Mahan Drive, MS-6 = 4 Tallahassee, Florida 32308-5403 na ‘ RE: Petition For Formal Administrative Hearing Dorsey L. Goosby, M.D., Provider No. 0682519-00 Final Agency Audit Report C.L. 94-1086-00/WJ2/VAS eo 2 —_ aod wn —_ Dear Mr. Noble: Enclosed is an original and one copy of a Petition For Formal Administrative Hearing in connection with the above referenced matter. Please accept the original for filing. Also, please date stamp the copy and return it to my courier. Should you have any questions, please feel free to contact me. CordjAlly, ty Mark K. Delegal MKD: law EXHIBIT Pc G:\USERS\Lori\ProNational\Goosby\PetitionCoverLTRO60101 .wpd

Docket for Case No: 03-001664MPI